Provider Demographics
NPI:1619020203
Name:SUZANNE E MACK, M.D., P.A.
Entity Type:Organization
Organization Name:SUZANNE E MACK, M.D., P.A.
Other - Org Name:NORTH TEXAS INSTITUTE FOR FUNCTIONAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-591-8447
Mailing Address - Street 1:728 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-2944
Mailing Address - Country:US
Mailing Address - Phone:940-591-8447
Mailing Address - Fax:940-484-5299
Practice Address - Street 1:728 N ELM ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-2944
Practice Address - Country:US
Practice Address - Phone:940-591-8447
Practice Address - Fax:940-484-5299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
F84490Medicare UPIN